Covered Entity Details

DSH050180B JOHN MUIR MEDICAL CENTER - WC (Approved) - information as of 4/25/2025 6:29:23 PM

Main Details

Name

JOHN MUIR MEDICAL CENTER - WC

Subdivision Name

MEDICAL IMAGING WC OSC - WCMC CT Scanner

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050180B

Medicare Provider Number

050180

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/3/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/21/2025

Last Recertification Date

Contacts

Authorizing Official

John Muir Health
Zach Harris, VP Ancillary Services
(808) 457-0157

Primary Contact

John Muir Health
Nikolai Tyler Dahl, Program Manager - Medication Utilization
(925) 947-3243

Addresses

Street Address

177 LA CASA VIA
STE 100
WALNUT CREEK, CA 94598-6101

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA	HSP40180F	1740215219

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050180A	Child	DSH	JOHN MUIR MEDICAL CENTER - WC	JM RAD ONCOLOGY OSCWC - Radiology-Diagnostic	177 LA CASA VIA	WALNUT CREEK	CA	Approved
DSH050180B	Child	DSH	JOHN MUIR MEDICAL CENTER - WC	MEDICAL IMAGING WC OSC - WCMC CT Scanner	177 LA CASA VIA	WALNUT CREEK	CA	Approved
DSH050180C	Child	DSH	JOHN MUIR MEDICAL CENTER - WC	MEDICAL IMAGING WC OSC - WCMC MRI	177 LA CASA VIA	WALNUT CREEK	CA	Approved
DSH050180D	Child	DSH	JOHN MUIR MEDICAL CENTER - WC	MEDICAL IMAGING WC OSC - WCMC Diagnostic Imaging	177 LA CASA VIA	WALNUT CREEK	CA	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Harris, Zach VP Ancillary Services John Muir Health 8084570157	4/21/2025 11:54 AM
Details	340B ID	Update	New Registration		DSH050180B	4/21/2025 11:54 AM
Details	Entity Subname	Update	New Registration	MEDICAL IMAGING WC OSC	MEDICAL IMAGING WC OSC - WCMC CT Scanner	4/21/2025 11:54 AM
Dates	Participating Approval Date	Update	New Registration		4/21/2025 11:54:26 AM	4/21/2025 11:54 AM
Details	State	Update	New Registration	Pending	Approved	4/21/2025 11:54 AM
Dates	Signed By Date	Update	New Registration		4/7/2025 4:17:08 PM	4/21/2025 11:54 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/21/2025 11:54 AM
Addresses	Main Address	Insert	New Registration		177 LA CASA VIA STE 100 WALNUT CREEK, CA 94598-6101	4/3/2025 5:05 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2025 5:05 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HSP40180F	4/3/2025 5:05 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/3/2025 5:05 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1740215219	4/3/2025 5:05 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/3/2025 5:05 PM
Contacts	Primary Contact	Insert	New Registration		Dahl, Nikolai Tyler Program Manager - Medication Utilization John Muir Health 9259473243	4/3/2025 5:05 PM
Contacts	Authorizing Official	Insert	New Registration		Harris, Zach VP Ancillary Services John Muir Health 8084570157	4/3/2025 5:05 PM
Details	Assistance Received From Date	Insert	New Registration			4/3/2025 5:05 PM
Details	Assistance Received To Date	Insert	New Registration			4/3/2025 5:05 PM
Details	Last Recertification Date	Insert	New Registration			4/3/2025 5:05 PM
Details	Grant Number	Insert	New Registration			4/3/2025 5:05 PM
Details	340B ID	Insert	New Registration			4/3/2025 5:05 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/3/2025 5:05 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/3/2025 5:05 PM
Details	Medicare Provider Number	Insert	New Registration		050180	4/3/2025 5:05 PM
Details	Entity Name	Insert	New Registration		JOHN MUIR MEDICAL CENTER - WC	4/3/2025 5:05 PM
Details	NOFO Number	Insert	New Registration			4/3/2025 5:05 PM
Details	Program Code	Insert	New Registration		DSH	4/3/2025 5:05 PM
Details	Entity Subname	Insert	New Registration		MEDICAL IMAGING WC OSC	4/3/2025 5:05 PM
Dates	Participating Approval Date	Insert	New Registration			4/3/2025 5:05 PM
Details	State	Insert	New Registration		Pending	4/3/2025 5:05 PM
Dates	Registration Date	Insert	New Registration		4/3/2025 5:05:52 PM	4/3/2025 5:05 PM
Dates	Signed By Date	Insert	New Registration			4/3/2025 5:05 PM
Dates	Start Date	Insert	New Registration			4/3/2025 5:05 PM
Terminations	Termination Comments	Insert	New Registration			4/3/2025 5:05 PM
Terminations	Termination Date	Insert	New Registration			4/3/2025 5:05 PM
Terminations	Termination Effective Date	Insert	New Registration			4/3/2025 5:05 PM
Terminations	Termination Reason	Insert	New Registration			4/3/2025 5:05 PM